In the Circuit Court of County, Kansas

IN THE DISTRICT COURT OF COUNTY, KANSAS Protection from Abuse (K.S.A. 60-3101 et seq.) Temporary Order of Protection from Abuse Judge or Division: Case Number: Court ORI Number:

Plaintiff: Plaintiff Identifiers:

Year of Birth (Date File Stamp)

Relationship to Defendant: are or have been in a dating Sex: F M relationship reside together or formerly resided together have a child in common

vs. Defendant: Defendant Identifiers:

SEX RACE YOB HT WT

Address HAIR EYES LAST 4 DIGITS OF SSN (IF KNOWN)

DRIVERS LICENSE DL STATE DL EXP. DATE #

Protected Person(s): Plaintiff Plaintiff’s child(ren) Minor child(ren) residing with the plaintiff (Only the party, or parties, initialed by the judge are protected person(s).)

This order and its terms are directed at and apply to Defendant only.

THIS TEMPORARY ORDER SHALL REMAIN IN EFFECT UNTIL SERVICE OF THE FINAL ORDER OR UNTIL TERMINATED BY ORDER OF THE COURT.

ONLY THE COURT CAN CHANGE THIS ORDER. The Court Finds: (Only the provision(s) initialed by the judge apply.)

Plaintiff filed a written verified petition on , 20 requesting a Temporary Order of Protection from Abuse. This court has jurisdiction over Plaintiff, Defendant and subject matter. This court has child custody jurisdiction because it is home state, there is no home state and Kansas has significant connections with the child(ren), temporary emergency jurisdiction, other: . Plaintiff has established good cause for the court to issue a temporary order of protection from abuse. A hearing has been set for , 20 , at : a.m. p.m., at (Court) and summons has been issued. The plaintiff’s address and telephone number shall remain confidential for the protection of the protected person(s).

07/01/2012 Page 1 of 3 Order The Court Orders:  The defendant shall not abuse, molest, or interfere with the privacy or rights of the protected person(s) wherever they may be. [ NCIC 01 & 02 ]  The defendant shall not use, attempt to use, or threaten to use physical force, that would reasonably be expected to cause bodily injury, against the protected person(s). [ NCIC 01 & 02 ]  The defendant shall not contact the protected person(s), either directly or indirectly, except as authorized by the court in paragraph 3(b) of this order. [ NCIC 04 & 05 ]  The defendant shall not direct or request another to contact the protected person(s), either directly or indirectly, except as authorized by the court in paragraph 3(b) of this order. [ NCIC 04 & 05 ]  The defendant shall not enter or come on or around the premises, the residence or workplace where the protected person(s) resides, stays or works. [ NCIC 04 ]  Law enforcement officers are directed to grant any assistance necessary to protect the protected person(s) from abuse by the defendant, and to provide any other assistance necessary to enforce these orders, including the order excluding the defendant from the protected person(s) place of residence, wherever it may be. [ NCIC 08 ]

CERTIFICATE OF COMPLIANCE WITH THE VIOLENCE AGAINST WOMEN ACT (VAWA): This Order meets all the requirements of the Violence Against Women Act, 18 U.S.C. § 2265. This Court has jurisdiction of the parties and the subject matter; the defendant has been afforded notice and a timely opportunity to be heard as provided by the laws of Kansas. This Order is enforceable in all 50 states, the District of Columbia, all Indian tribal courts and all United States territories and shall be enforced as if it were an order of that jurisdiction pursuant to 18 U.S.C. § 2265.

Additional terms of this order are set forth below. (Only the provision(s) initialed by the judge apply.)

Housing and Property: 1. The plaintiff is granted exclusive possession of the residence located at: . [ NCIC 03 ] If the plaintiff is granted exclusive possession of the residence, the defendant shall immediately move from the residence and may take only personal clothing and effects until further order of the court. Law enforcement officials are directed to remove the defendant from the residence, and to ensure that Defendant does not enter or re-enter the premises or any other residence the plaintiff may occupy. 2. Defendant shall not cancel utilities to the residence. The terms of this paragraph expire 60 days from this order’s date of entry. [ NCIC 08 ]

Parentage and Custody: 3. For this paragraph, the court shall initial subparagraph (a) OR subparagraph (b), but not both. a. Defendant’s parentage of the child(ren) has not been established through a marriage of the parties or pursuant to the Kansas Parentage Act, K.S.A. 23-2201 et seq., and Defendant has no right to custody or parenting time with the following named child(ren): . b. Defendant’s parentage of the child(ren) has been established through the marriage of the parties or pursuant to the Kansas Parentage Act, K.S.A. 23-2201 et seq., and the following custody and parenting time orders are entered: i. Temporary legal custody and residency of the following named minor child(ren): . [ NCIC 09 ] shall be: Joint legal custody between the plaintiff and defendant until this order expires; or, Sole legal custody granted to Plaintiff Defendant until this order expires. [ NCIC 06 ]

07/01/2012 Page 2 of 3 ii. Rights of temporary parenting time shall be as follows: [ NCIC 06 ] Plaintiff and Defendant shall have parenting time as described in the attached parenting plan; Defendant shall have no parenting time; Defendant shall have supervised parenting time as follows: ; Plaintiff and Defendant shall exchange the minor child(ren) for parenting time at:

SO ORDERED:

Date Judge of the District Court

WARNINGS TO DEFENDANT

 This order is effective when signed by the judge. Law enforcement officials shall immediately enforce this order.  Violation of this order may constitute: violation of a protective order as provided in K.S.A. 21-5924, and amendments thereto; assault as provided in K.S.A. 21-5412(a), and amendments thereto; battery as provided in K.S.A. 21-5413(a), and amendments thereto; and domestic battery as provided in K.S.A. 21-5414, and amendments thereto, and may result in prosecution and conviction under Kansas criminal statutes.  If possession of the residence is granted to the plaintiff, violation of this order by the defendant constitutes criminal trespass pursuant to K.S.A. 21-5808(a)(1)(C), and amendments thereto, and may result in prosecution and conviction under Kansas criminal statutes.  Violation of this order may also be punishable as contempt of this court.  If the defendant has a concealed carry license, that license is subject to revocation pursuant to K.S.A. 75-7c07, and amendments thereto. After a defendant’s concealed carry license has been revoked, continuing to carry a concealed weapon may constitute a violation of K.S.A. 21-6302, and amendments thereto.  Violation of this order may subject the defendant to prosecution for such federal crimes, including but not limited to: Interstate travel to commit domestic violence; Interstate stalking; and Interstate violation of a protection order.

Notice of Extension of this Temporary Order (Pursuant to K.S.A. 60-3106) If a hearing on the petition for protection is continued, the court may extend this Temporary Order of Protection from Abuse for additional periods of time as it deems necessary.

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